Disparities in Post-Discharge Care

Patients discharged from the hospital after a heart attack or heart failure face high rates of readmission and death, with significant disparities among different groups. While programs like the Hospital Readmissions Reduction Program have aimed to improve post-discharge care, the results have been mixed.

Early follow-up care after discharge is crucial for managing medications, detecting complications, and preventing readmissions. However, current data on the frequency and effectiveness of this follow-up care is limited. 

A recent study published in the Annals of Internal Medicine assessed trends and disparities in post-discharge care for patients hospitalized with heart attacks or heart failure. Senior author, Professor Bruce Landon, MD, MBA, MSc, Associate Professor Laura Hatfield, PhD, and biostatistician Jeffrey Souza, from the Harvard Department of Health Care Policy, contributed to the study led by Timothy S. Anderson.

The researchers analyzed Medicare data from 2010 to 2019 to determine the percentage of patients who received a cardiology follow-up within 30 days of hospital discharge. They found that while overall follow-up rates increased during this period, significant disparities persisted.

Key findings:

  • Increased follow-up: There was a modest increase in cardiology follow-up rates for patients discharged after heart attacks (AMI) and heart failure (HF) between 2010 and 2019.
  • Persistent gaps: Despite improvements, a significant proportion of patients did not receive timely cardiology or primary care follow-up.
  • Widening disparities: While follow-up rates increased for all groups, disparities worsened for minority, low-income, and rural patients.

These findings suggest that achieving equitable care requires a comprehensive approach. Fostering collaboration between cardiology and primary care providers during the transition from hospital to home, expanding opportunities for timely follow-up appointments, and evaluating diverse transitional care models to identify optimal practices can help to ensure equitable access to post-discharge care for all patients.